Descriptions of Race from Page 2 Above
Name: / Date:
Organization:
E-mail:
Address:
Primary Phone: / Secondary Phone:
Cell Phone: / Fax:
Website:
SECTION II: PANELS TO WHICH YOU ARE APPLYING
I want to be considered as an: / Arbitrator / Mediator
*Submission of this application will automatically consider you for CPR’s General Commercial Panel (which is divided regionally, based on your address above). In addition, you MAY want to apply to some of the specialty panels below. Acceptance to most of these panels is governed by user/peer-review committees. Acceptance to these panels may take upwards of 6 months. Furthermore, once accepted, listing on one or more specialty panels incurs additional annual administrative fees.
*General Commercial Panel Processing fee $150; EACH additional specialty panel (except pro-bono) $50
Arbitration Appeal
(US Appellate Judges only) / Banking, Accounting and Financial Services / Bio-Tech / Certified Public Accountants (CPAs Only)
Construction* / Cyber Panel / Deal Facilitation / E-Discovery*
Employment* / Energy, Oil & Gas* / Entertainment / Environmental
Franchise / General Counsel
(former GCs Fortune 500) / Healthcare & Life Sciences / Hedge Funds
Insurance* / Insurer-Policy Holder Coverage / International* / Judicial Roster
Municipal Bankruptcy / Product Liability / Real Estate / Sports Law
Taxation / Technology* / Trademark
I would like to be queried for Pro-Bono Cases
*Requires addendum at end of application
For all specialty panels that do NOT require completion of an addendum, please describe your qualifications for the specified panel(s), e.g., percent of time spent in training or practice in that area, description of cases handled, etc. Without this information, we cannot evaluate your experience in the field:
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SECTION III: ADDITIONAL PERSONAL INFORMATIONA. Responses to the following questions on Race, Gender and Citizenship are optional.
Race:
(See descriptions on page 8)
Gender:
Citizenship:
Languages:
Note fluency level (e.g. fluent; read-only)
Are you licensed to practice before the U.S. Patent & Trademark Office? / Y N / Are you a CPA? / Y N
Have you ever had a U.S. Government Security Clearance?
**Note dates and level: / Y N / Are you IMI certified? / Y N
B. Please describe your experience AS A JUDGE. Please check all that apply and specify court and time period.
Federal Court - Appellate Level: / Federal Court - Trial Level:
Federal Court – Other: / State Court - Appellate Level:
State Court - Trial Level: / State Court – Other:
Foreign Court: / Quasi-Judicial (specify admin. agency ):
C. General Education, for additional space in sections C-G below, please add rows to the table or provide an addendum
Degree / Major / Institution / Year
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2.
3.
4.
D. ADR Education & Training
Arb/Med/Both / Hours / Institution / Year
1.
2.
3.
4.
5.
E. Licenses – (Law, CPA, Engineering, Architectural, Other)
Type / State/Country / Court/Agency / Current?
1.
2.
3.
4.
F. Work History
Organization / City, State / Title / Year Span
1.
2.
3.
4.
5.
6.
7.
8.
G. ADR Rosters – list any neutral rosters maintained by any ADR organizations of which you are a part ( e.g., AAA, JAMS, CEDR, ICC, International Academy of Mediators, Regional Provider, Government Agency Roster, Court Roster, Other? )
Organization / Year Accepted
1.
2.
3.
SECTION IV: NEUTRAL EXPERIENCE
Please provide your best estimate of the number of times you have been a Neutral and/or an Advocate in the following types of ADR procedures, if applicable to you:
A. Arbitration Experience
Overall / Last 12 Mos.
Total number times served as Arbitrator of any sort:
Total number times served as Sole Arbitrator:
Total number of times served as Tribunal Chair:
Total number of times served as Class Action Arbitrator:
Total number of times advocated for a client in an Arbitration:
B. Mediation Experience
Overall / Last 12 Mos.
Total number times served as Mediator of any sort:
Total number times served as Co-Mediator:
Total number of times served as Multi-Party Mediator:
Total number of times served as Process Design Mediator:
Total number of times advocated for a client in a Mediation:
Please briefly describe your philosophical approach to mediation:
C. Other ADR Experience
Early Neutral Evaluation / Overall / Last 12 Mos.
Total number times served as Neutral:
Total number times served as Advocate:
Mini-Trial Chair
Total number times served as Neutral:
Total number times served as Advocate:
Private Judging
Total number times served as Neutral:
Total number times served as Advocate:
Summary Jury Trial
Total number times served as Neutral:
Total number times served as Advocate:
Facilitation of Multi-Party Defense
Total number times served as Neutral:
Dispute Review Board Member
Total number times served as Neutral:
Dispute Review Board Chair
Total number times served as Neutral:
Partnering Neutral
Total number times served as Neutral:
Ombudsperson
Total number times served:
Other
D. If you feel that the numerical range you checked off does not fully reflect the depth of your experience (e.g., you served as mediator just once but it was an unusually protracted and complex matter), please describe:
E. Representative Matters – if you would like to provide CPR with a further sampling of the matters in which you presided over as an arbitrator or mediator or acted as counsel please do so here. Please do not list party names, but use descriptive terms (e.g. large pharma co.) unless the matter is in the public record.
1.
2.
3.
4.
5.
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SECTION V: AREAS OF CONCENTRATIONThese are areas in which you already have experience, rather than areas in which you are interested.
A. ARBITRATION – concentrations in which you have acted as arbitrator.
GENERAL CONCENTRATIONS
Accounting - Forensic / Accounting - General / Accounting - Litigation / Accounting - Valuation
Administrative law / Agriculture / Antitrust / Asbestos
Automotive / Aviation/Aerospace / Banking / Bankruptcy
Business Disputes / Chemicals / Civil Rights & Liberties / Class Action (D Side)
Class Action (Neutral) / Class Action (P Side) / Commercial Law / Commodities
Communications & Media / Community Organizations / Computer law / Construction
Consumer Affairs / Contract-Government / Contract-Manufacturing / Copyright
Corporate (Financing) / Corporate (General) / Corporate (Governance) / Corporate (Transactions)
Corporate (Underwriting) / Deal Facilitation / Debtor/Creditor / Defamation/1st Amendment
Domain Name / Education / Employment / Energy, Oil & Gas
Entertainment / Environmental (Cleanup) / Environmental (General) / Environmental (Regulatory)
False Advertising/FTC / Financial Services / Franchise / Fraud/Misrepresentation
Hedge Funds / Housing & Urban Dev. / Information Technology / Insurance
Intellectual Property / International (Environ) / International (General) / International (Trade)
International (Transactions) / Labor Relations / Leasing / Licensing (General)
Licensing (Software) / Malpractice (Legal) / Manufacturing / Maritime
Merger & Acquisition / Mining / Municipal Law / Natural Resources
Non-Profit Organizations / Partnership Disputes / Patents/Trade Secret / Personal Injury
Product Liability / Professional Fees / Real Estate (Banking & Finance) / Real Estate (Development)
Real Estate (General) / Real Estate (Land Use/Zoning) / Real Estate (Leasing) / Regulated Industries
Reinsurance / Religious Entities / RICO / Securities
Sports Law / SWAPS and/or Derivatives / Taxation (Corporate) / Taxation (General)
Taxation (Individual) / Taxation (International) / Taxation (Partnership) / Technology/Science
Torts (Business & Property) / Torts (General) / Torts (Mass) / Torts (Toxic)
Trademark / Trade Secrets / Transportation / Tribal and Indian Affairs
Trusts & Estates / Unfair Competition / Water Law / Workouts
CONSTRUCTION SPECIALTY SUB-CONCENTRATIONS
Construction Defects / Claims for Delay / Claims for Extras / General Building Construction
Government Contracts / Hazardous Waste / Health Facilities / Industrial (Mill, Refin., Pharma)
Insurance (Indemnity & Contrib.) / International (incl. FIDIC) / Manufacturing Construction / Marine
Mold / Petroleum / Power / Sewage/Solid Waste
Available – Const. Expedited Rules / Telecommunications / Transportation (Bridges,Roads…etc.) / Water Supply
Other - Construction
EMPLOYMENT SPECIALTY SUB-CONCENTRATIONS
Civil Rights and Compensation / Employee Benefits/Erisa / Executive Compensation / FLSA
Statutory Discrimination Claims / Other - Employment
Energy, Oil & Gas SPECIALTY SUB-CONCENTRATIONS
Alternative/Renewable Energy / Coal Industry / Rural Electric Co-op Industry / Electric Distribution
Electric Generation / Electric/Power Marketing / Electric Transmission / Expropriation
Liquefied Natural Gas / Natural Gas Pipeline / Nuclear / Oil & Gas
Oil/NG Distribution / Oil/NG Explor./Produc. / Oil/NG Marketing / Oil Pipelines
Refining & Petrochemical / Risk Management Services / Selected Natural Gas Issues / Selected Oil Issues
Selected Upstream Issues / Selected Upstream Issues / Solar / Other – Energy
Healthcare & Life Sciences SPECIALTY SUB-CONCENTRATIONS
Biotech / Dental / Food, Drug & Cosmetics / Healthcare
Hospital Law / Licensing (Medical) / Life Sciences / Malpractice (Medical)
Managed Care / Medical Devices / Medical Research Ventures / Peer Review
Pharmaceuticals / Physicians / Reimbursement Disputes / Other - Healthcare
Insurance SPECIALTY SUB-CONCENTRATIONS
Construction Defect Insurance / Cyber Insurance / D&O Insurance / Environmental Insurance
Fidelity Bond / Financial Institutions Insurance / Insurance General / Insurance Health
Insurance Life / Insurance Property & Casualty / Reinsurance / Insurance Telecomm
Other - Insurance
Technology/Intellectual Property SPECIALTY SUB-CONCENTRATIONS
Aeronautics / Biology / Biotechnology / Business Methods
Materials (polymers, ceramics…) / Chemistry / Computers & Software / Electrical
Electronics / Intellectual Property / Internet / Mechanical
Medical Devices / Nanotechnology / Optics / Patents
Pharmaceuticals / Privacy/EU Safe Harbor / Robotics/Machine Vision / Semiconductors
Signal Process/Video/CommSysts / Telecommunications / Textiles / Other - Technology/IP
Cyber Security
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B. MEDIATION – concentrations in which you have acted as mediator.GENERAL CONCENTRATIONS
Accounting - Forensic / Accounting - General / Accounting - Litigation / Accounting - Valuation
Administrative law / Agriculture / Antitrust / Asbestos
Automotive / Aviation/Aerospace / Banking / Bankruptcy
Business Disputes / Chemicals / Civil Rights & Liberties / Class Action (D Side)
Class Action (Neutral) / Class Action (P Side) / Commercial Law / Commodities
Communications & Media / Community Organizations / Computer law / Construction
Consumer Affairs / Contract-Government / Contract-Manufacturing / Copyright
Corporate (Financing) / Corporate (General) / Corporate (Governance) / Corporate (Transactions)
Corporate (Underwriting) / Debtor/Creditor / Defamation/1st Amendment / Domain Name
Education / Employment / Energy, Oil & Gas / Entertainment
Environmental (Cleanup) / Environmental (General) / Environmental (Regulatory) / False Advertising/FTC
Financial Services / Franchise / Fraud/Misrepresentation / Hedge Funds
Housing & Urban Dev. / Information Technology / Insurance / Intellectual Property
International (Environ) / International (General) / International (Trade) / International (Transactions)
Labor Relations / Leasing / Licensing (General) / Licensing (Software)
Malpractice (Legal) / Manufacturing / Maritime / Merger & Acquisition
Mining / Municipal Law / Natural Resources / Non-Profit Organizations
Partnership Disputes / Patents/Trade Secret / Personal Injury / Product Liability
Professional Fees / Real Estate (Banking & Finance) / Real Estate (Development) / Real Estate (General)
Real Estate (Land Use/Zoning) / Real Estate (Leasing) / Regulated Industries / Reinsurance
Religious Entities / RICO / Securities / Sports Law
SWAPS and/or Derivatives / Taxation (Corporate) / Taxation (General) / Taxation (Individual)
Taxation (International) / Taxation (Partnership) / Technology/Science / Torts (Business & Property)
Torts (General) / Torts (Mass) / Torts (Toxic) / Trademark
Trade Secrets / Transportation / Tribal and Indian Affairs / Trusts & Estates
Unfair Competition / Water Law / Workouts / Deal Facilitation
CONSTRUCTION SPECIALTY SUB-CONCENTRATIONS
Construction Defects / Claims for Delay / Claims for Extras / General Building Construction
Government Contracts / Hazardous Waste / Health Facilities / Industrial (Mill, Refin., Pharma)
Insurance (Indemnity & Contrib.) / International (incl. FIDIC) / Manufacturing Construction / Marine
Mold / Petroleum / Power / Sewage/Solid Waste
Available – Const. Expedited Rules / Telecommunications / Transportation (Bridges,Roads…etc.) / Water Supply
Other - Construction
EMPLOYMENT SPECIALTY SUB-CONCENTRATIONS
Civil Rights and Compensation / Employee Benefits/Erisa / Executive Compensation / FLSA
Statutory Discrimination Claims / Other - Employment
Energy, Oil & Gas SPECIALTY SUB-CONCENTRATIONS
Alternative/Renewable Energy / Coal Industry / Rural Electric Co-op Industry / Electric Distribution
Electric Generation / Electric/Power Marketing / Electric Transmission / Expropriation
Liquefied Natural Gas / Natural Gas Pipeline / Nuclear / Oil & Gas
Oil/NG Distribution / Oil/NG Explor./Produc. / Oil/NG Marketing / Oil Pipelines
Refining & Petrochemical / Risk Management Services / Selected Natural Gas Issues / Selected Oil Issues
Selected Upstream Issues / Selected Upstream Issues / Solar / Other – Energy
Healthcare & Life Sciences SPECIALTY SUB-CONCENTRATIONS
Biotech / Dental / Food, Drug & Cosmetics / Healthcare
Hospital Law / Licensing (Medical) / Life Sciences / Malpractice (Medical)
Managed Care / Medical Devices / Medical Research Ventures / Peer Review
Pharmaceuticals / Physicians / Reimbursement Disputes / Other - Healthcare
Insurance SPECIALTY SUB-CONCENTRATIONS
Construction Defect Insurance / D&O Insurance / Environmental Insurance / Fidelity Bond
Financial Institutions Insurance / Insurance General / Insurance Health / Insurance Life
Insurance Property & Casualty / Reinsurance / Insurance Telecomm / Other - Insurance
Cyber Insurance
Technology/Intellectual Property SPECIALTY SUB-CONCENTRATIONS
Aeronautics / Biology / Biotechnology / Business Methods
Materials (polymers, ceramics…) / Chemistry / Computers & Software / Electrical
Electronics / Intellectual Property / Internet / Mechanical
Medical Devices / Nanotechnology / Optics / Patents
Pharmaceuticals / Privacy/EU Safe Harbor / Robotics/Machine Vision / Semiconductors
Signal Process/Video/CommSysts / Telecommunications / Textiles / Other – Technology/IP
Cyber Security
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C. PROFESSIONAL PRACTICE – concentrations in which you have acted during professional practice.GENERAL CONCENTRATIONS
Accounting - Forensic / Accounting - General / Accounting - Litigation / Accounting - Valuation
Administrative law / Agriculture / Antitrust / Asbestos
Automotive / Aviation/Aerospace / Banking / Bankruptcy
Business Disputes / Chemicals / Civil Rights & Liberties / Class Action (D Side)
Class Action (Neutral) / Class Action (P Side) / Commercial Law / Commodities
Communications & Media / Community Organizations / Computer law / Construction
Consumer Affairs / Contract-Government / Contract-Manufacturing / Copyright
Corporate (Financing) / Corporate (General) / Corporate (Governance) / Corporate (Transactions)
Corporate (Underwriting) / Debtor/Creditor / Defamation/1st Amendment / Domain Name
Education / Employment / Energy, Oil & Gas / Entertainment
Environmental (Cleanup) / Environmental (General) / Environmental (Regulatory) / False Advertising/FTC
Financial Services / Franchise / Fraud/Misrepresentation / Hedge Funds
Housing & Urban Dev. / Information Technology / Insurance / Intellectual Property
International (Environ) / International (General) / International (Trade) / International (Transactions)
Labor Relations / Leasing / Licensing (General) / Licensing (Software)
Malpractice (Legal) / Manufacturing / Maritime / Merger & Acquisition
Mining / Municipal Law / Natural Resources / Non-Profit Organizations
Partnership Disputes / Patents/Trade Secret / Personal Injury / Product Liability
Professional Fees / Real Estate (Banking & Finance) / Real Estate (Development) / Real Estate (General)
Real Estate (Land Use/Zoning) / Real Estate (Leasing) / Regulated Industries / Reinsurance
Religious Entities / RICO / Securities / Sports Law
SWAPS and/or Derivatives / Taxation (Corporate) / Taxation (General) / Taxation (Individual)
Taxation (International) / Taxation (Partnership) / Technology/Science / Torts (Business & Property)
Torts (General) / Torts (Mass) / Torts (Toxic) / Trademark
Trade Secrets / Transportation / Tribal and Indian Affairs / Trusts & Estates
Unfair Competition / Water Law / Workouts / Deal Facilitation
CONSTRUCTION SPECIALTY SUB-CONCENTRATIONS
Construction Defects / Claims for Delay / Claims for Extras / General Building Construction
Government Contracts / Hazardous Waste / Health Facilities / Industrial (Mill, Refin., Pharma)
Insurance (Indemnity & Contrib.) / International (incl. FIDIC) / Manufacturing Construction / Marine
Mold / Petroleum / Power / Sewage/Solid Waste
Available – Const. Expedited Rules / Telecommunications / Transportation (Bridges,Roads…etc.) / Water Supply
Other - Construction
EMPLOYMENT SPECIALTY SUB-CONCENTRATIONS
Civil Rights and Compensation / Employee Benefits/Erisa / Executive Compensation / FLSA
Statutory Discrimination Claims / Other - Employment
Energy, Oil & Gas SPECIALTY SUB-CONCENTRATIONS
Alternative/Renewable Energy / Coal Industry / Rural Electric Co-op Industry / Electric Distribution
Electric Generation / Electric/Power Marketing / Electric Transmission / Expropriation
Liquefied Natural Gas / Natural Gas Pipeline / Nuclear / Oil & Gas
Oil/NG Distribution / Oil/NG Explor./Produc. / Oil/NG Marketing / Oil Pipelines
Refining & Petrochemical / Risk Management Services / Selected Natural Gas Issues / Selected Oil Issues
Selected Upstream Issues / Selected Upstream Issues / Solar / Other – Energy
Healthcare & Life Sciences SPECIALTY SUB-CONCENTRATIONS
Biotech / Dental / Food, Drug & Cosmetics / Healthcare
Hospital Law / Licensing (Medical) / Life Sciences / Malpractice (Medical)
Managed Care / Medical Devices / Medical Research Ventures / Peer Review
Pharmaceuticals / Physicians / Reimbursement Disputes / Other - Healthcare
Insurance SPECIALTY SUB-CONCENTRATIONS
Construction Defect Insurance / D&O Insurance / Environmental Insurance / Fidelity Bond
Financial Institutions Insurance / Insurance General / Insurance Health / Insurance Life
Insurance Property & Casualty / Reinsurance / Insurance Telecomm / Other - Insurance
Cyber Insurance
Technology/Intellectual Property SPECIALTY SUB-CONCENTRATIONS
Aeronautics / Biology / Biotechnology / Business Methods
Materials (polymers, ceramics…) / Chemistry / Computers & Software / Electrical
Electronics / Intellectual Property / Internet / Mechanical
Medical Devices / Nanotechnology / Optics / Patents
Pharmaceuticals / Privacy/EU Safe Harbor / Robotics/Machine Vision / Semiconductors
Signal Process/Video/CommSysts / Telecommunications / Textiles / Other - Technology/IP
Cyber Security
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SECTION VI: REFERENCESYou must provide CPR with reference information for parties/attorneys who appeared before you in your capacity as an arbitrator and/or mediator, from the same case.
References will be asked to provide an account of your skills as a neutral. Note that CPR will never ask for confidential case information.
Applications without reference information will not be processed.
A. References as an Arbitrator*
Case Description (Provide Dispute Type, Amount in Dispute and Year):
Name / Law Firm/Company / City, State / Phone / E-mail
For Claimant:
(or CPR Arbitrator)
For Respondent:
(or CPR Arbitrator)
* You may also submit references from a CPR panelist who has sat with you as an arbitrator
B. References as a Mediator*
Case Description (Provide Dispute Type, Amount in Dispute and Year):
Name / Law Firm/Company / City, State / Phone / E-mail
For Claimant:
For Respondent:
* If you are an IMI certified mediator, you may submit your feedback digest in lieu of references
*You may provide written recommendation letters that speak to your skills as an arbitrator and/or mediator in lieu of the above.
SECTION VII: OTHER
Provide any honors, publications or other information you believe are relevant to your application.
Descriptions of race from page 2 above: